AdventHealth Corporate

All the benefits and perks you need for you and your family:

• Benefits from Day One

• Career Development

• Whole Person Wellbeing Resources

• Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Shift : Full-time; Monday-Friday

Job Location : Remote

The role you'll contribute:

The Denials Management Coding Specialist is high level coding expert responsible for investigating and resolving coding related denials from payers, preventing lost reimbursement and promoting denial prevention. The Denials Management Coding Specialist addresses both Inpatient and Outpatient claims and serves as a resource for all coding related questions and guidance to the Centralized Denial Team. The Denials Management Coding Specialist will adhere to the AdventHealth Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies.

The value that you bring to the team:

• Expert coding level knowledge of medical terminology, anatomy & physiology and pathophysiology

• Expert knowledge and understanding of Coding guidelines, Medicare & Medicaid CCI & MUE edits, CPT, HCPCS, ICD, LCD/NCD, UHDDS data sets, UB-04 Revenue Codes, NDC codes, device codes, coding related condition codes, HACs, HCCs, POAs, SOI/ROM, PSIs, PPS-RVU files, modifiers, billing regulations and guidelines for government and commercial payers

• Knowledge and understanding of the MS-DRG, APR-DRG, HIPPS, CMG, APC, EAPG, physician-fee-for service reimbursement systems

• Knowledgeable with billing/coding requirements for clinical trials/studies.

• Ability to navigate CMS, Federal Register, AHA, FDA, MAC and payer websites to locate all policies necessary to correct/appeal denials

• Ability to locate and analyze all documentation necessary to interpret services performed, and correlate/audit charges on the bill

• Ability to analyze all aspects of a medical record to locate documentation necessary to support medical necessity

• Ability to analyze Explanations of Benefits/remittance advice, claims, payer denial and DRG downgrade letters to identify the root cause of the denial/downgrade and correction(s) needed

• Ability to identify documentation and coding guidelines/regulations/edits to defend the claim as billed or support the payer's denial for corrections needed

• Ability to analyze and interpret complex NCD/LCD guidelines, CMS/AHCA policies and regulations

• Ability to write clear and concise appeal letters utilizing all available documentation, regulations and guidelines to defend claim as billed.

• Proficiency in all services lines - inpatient, observation, ED, outpatient surgery (general, gynecological, obstetrical, cardiovascular, orthopedic, podiatric), clinical laboratory, radiation oncology, infusions, chemotherapy, physical/occupational/speech/cardiac/pulmonary rehabilitation, radiology/imaging, interventional radiology, etc.

• Proficiency in Microsoft Suite applications specifically Excel, Word, OneNote, Outlook, and Teams

• Demonstrates high-level critical thinking and problem-solving skills with ability to multi-task or reprioritize quickly in a high productivity, fast paced environment.

• Tracks and reports opportunities to supervisor for denial prevention and coding, billing, charge posting education opportunities

• Tracks and reports to supervisor outcomes of conflicts with payers denials, policies and resubmitted claims

• Maintains a current knowledge of ICD-10-CM/CPT coding updates and changes through Coding Clinics and seminars, as well as changes in the Medicare/Insurance industry and brings identified concerns to supervisor for resolution

• Technical proficiency within the 3m, Dolbey CAC, EPIC, Cerner, CPA, Waystar software, ICD-10-CM code books, CPA Assistant, Coding Clinics and all embedded encoder resources per established coding principals and guidelines

• Ability to navigate multiple concurrent various modules within applicable technologies to perform account research

• Ability and willingness to continuously learn new concepts and skill required to navigate ever-changing reimbursement/denials landscape

• Self-starter with the ability to work under limited day-to-day oversight in a remote setting

• Ability to educate others regarding coding guidelines

Qualifications
The expertise and experiences you'll need to succeed :

• At least one year experience working payer denials for medical necessity, SSI and NCCI edits, incorrect procedure/diagnosis coding

• At least five years recent acute care coding experience to include; Inpatient acute, inpatient rehabilitation, inpatient behavioral health, ED, observation, outpatient behavioral health, radiation oncology, chemotherapy/infusions, rehabilitative therapy, skilled nursing, surgery, interventional radiology, clinical laboratory and imaging/radiology coding.

• Experience with HCPCS codes and resolution of OCE edits, SSI edits and CCI edits

• Familiarity of the DRG reimbursement system

• Medical Necessity and DRG appeal writing experience

• Coding Audit experience

• High school diploma or equivalent

• RHIA, RHIT, CPC, or CCS certification or credential

Preferred Qualifications :

• Advanced degree in any clinical, medical or business field of study

• Experience in HIM, clinical documentation improvement, revenue integrity, or related field

• Patient Financial Services experience

• Certification Clinical Documentation (CDIP)

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